Provider Demographics
NPI:1356709422
Name:OPTICAL ADVANTAGE PC
Entity type:Organization
Organization Name:OPTICAL ADVANTAGE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-253-8111
Mailing Address - Street 1:6 BRIARCLIFFE RD
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4021
Mailing Address - Country:US
Mailing Address - Phone:917-548-5083
Mailing Address - Fax:718-253-2333
Practice Address - Street 1:6 BRIARCLIFFE RD
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4021
Practice Address - Country:US
Practice Address - Phone:917-548-5083
Practice Address - Fax:718-253-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty